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Abstract
Objectives The perspective of general practitioners’ (GPs) on retirement and the factors influencing their attitude towards retirement have been previously investigated. However, while the number of GPs has been declining for many years in France, leading to the emergence of medical deserts, the impact on their patients remains to be explored. The aim of this study was to understand patients’ perceptions of their GP’s retirement.
Design A semistructured interview-based qualitative study was conducted, using Interpretative Phenomenological Analysis.
Setting Interviews were conducted in two general practices located in Essonne, Ile-de-France, France, between January and April 2014.
Participants Thirteen women and five men, aged 21–94 years, were included in this study. Exclusion criteria were the non-declaration of the physician as the declared doctor and being under 18 years of age.
Results The GP–patient relationship is a link that is built up over time, over the course of several consultations. Patients choose their GP based on qualities or skills they value. In this way, the physician chosen is unique for their patients; this choice reflects a certain loyalty to their physician. The interaction with the family sphere reinforces this relationship through the multiple links created during care. When a GP retires, this link is broken. Patients’ reactions can range from indifference to real grief.
Conclusion This study confirms the importance of the link between the GPs and their patients and highlights the need to prepare patients for their GP’s retirement.
- QUALITATIVE RESEARCH
- Patient Satisfaction
- Primary Care
- Organisation of health services
- Life Change Events
Data availability statement
No data are available. No additional data available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- QUALITATIVE RESEARCH
- Patient Satisfaction
- Primary Care
- Organisation of health services
- Life Change Events
Strengths and limitations of this study
The interview guide was developed based on a literature review on the topic of retirement.
Patients were included until data saturation was reached when two interviews did not bring any new elements to the analysis.
Data collection was anonymous; some patients refused to participate without being asked why.
Interviews were conducted by a male doctoral student with no prior experience in qualitative research; however, the research team had experience in qualitative research and the interview data were triangulated by two physicians trained in Interpretative Phenomenological Analysis.
Patients were recruited from two general practitioner practices, both located in Essonne, Ile-de-France, France; the findings may not be transferable to other geographical areas.
Introduction
According to the Medical Demography Atlas, the number of general practitioners (GPs) regularly practising in France as of 1 January 2022, has decreased by 11% since 2010 and by 0.9% in the past year. This decline is anticipated to continue over the next decade, largely due to the retirement of nearly a quarter of the workforce. With more than a quarter of these practitioners being over 60 years old, a further reduction in their numbers is likely in the coming years.1
Per Hedden et al, in 2021, only 54% of Canadian patients managed to find a new physician following the retirement of their primary care physician, leaving almost half of the patients without a designated doctor.2 For Sabety et al, in 2020 in the USA, the loss of a primary care physician was associated with an increased use of specialty and urgent care and an increase in healthcare expenditures.3
Several studies have shown that GPs experience strong emotions when they retire.4 The GPs’ perspective on their retirement mainly depends on the care relationship they have established with their patients, and the strength of the bond between them and their patients.5 6 While the GPs’ perspective is well known, what about the patients’ perspective? The declared doctor is the first-line practitioner, the primary caregiver and patients’ primary contact within the healthcare system. So, when their GP retires, patients lose the caregiver who has accompanied and followed them for many years. They also lose someone with whom they had built up a lasting relationship of trust.7 A study has analysed the ‘thank you’ messages sent to GPs at the time of their retirement, and has highlighted the qualities (‘being present’, ‘caring’, ‘medical expertise’, etc) valued by the patients in their relationship with the physician.8 Another publication by a GP has reported his retirement party during which he shared with his patients the most memorable moments in their care, revealing the intensity of the bond that unites patients and their physician.9 This retirement is therefore probably as difficult for patients as it is for physicians. The literature review by Lam et al has highlighted the topics most frequently cited by patients: emotional distress (in particular, feeling of abandonment), difficulty in transitioning to a new care provider, difficulty in accessing care and increased use of more expensive services.10
In addition, the number of GPs has been steadily decreasing for many years, leading to the emergence of medical deserts.11 12 Thus, this lack of medical handover represents a risk for the continuity of care. Currently, when a physician retires, there is no institutional system allowing patients to automatically find a new declared doctor. There are several possible situations: the physician has found a successor, in which case the continuity of care is facilitated, or the physician has not found a physician to replace him, in which case he refers patients to other physicians likely to follow them. Patients will get their medical file back and will then have to consult this new physician to whom they have been referred. Thus, the difficulty in finding a new declared doctor in a context of physician shortage is associated with the loss of their main health contact, a situation that could potentially complicate the continuity of care. Also, to the best of our knowledge, patients’ perspective on their GP’s retirement has not been thoroughly investigated. A study conducted by the DRESS published in April 202113 has investigated patients’ experience of the difficulties in accessing care. The aim of this study was to assess how patients experience the retirement of their GP, by questioning patients from two medical practices in Essonne, Ile-de-France, France.
Methods
Study design and participants
An Interpretative Phenomenological Analysis (IPA) was used to qualitatively assess differences between participants sharing the same experience. Therefore, a homogeneous sampling was obtained in these qualitative semistructured interviews. However, some differences in the sociodemographic characteristics of participants were expected: age, gender, follow-up duration, number of annual consultations (absence or presence of chronic diseases).14 Patients from the practices of two GPs located in Essonne, Ile-de-France, France, were included. These two physicians were selected from the Sorbonne University network of internship supervisors. Indeed, at the time this study was designed, these two practitioners were about to retire, and they agreed to the conduct of the study among their patients. In France, all patients are required to indicate a declared doctor to the Caisse Primaire d'Assurance Maladie (primary health insurance funds). It is therefore exceptional that patients who are regularly followed by a GP have not declared him as their declared doctor. For this reason, patients who had not declared the study physicians as their declared doctors, as well as minors (under the age of 18) were excluded from the study. The appointment times were chosen at different times of the day and on different days of the week. A face-to-face contact with the patients was used. Patients were included until data saturation was reached. Data saturation was considered reached when two completed interviews did not provide any new elements to the analysis.
There was no relationship between the participants and the interviewer. The interviewer was a man. At the beginning of each interview, he introduced himself as a future GP completing his medical thesis. He then provided information on the study and obtained oral consent from the patients. All interviews were conducted using the same interview guide prepared beforehand (online supplemental appendix 1). No notes were taken on site during the interviews. All audio recordings and transcripts were saved on a password-secured computer. Confidentiality was maintained using numbers instead of names (eg, E16, F, patient followed for 27 years) and all identifying information was removed from the transcripts.
Supplemental material
Procedures
The interview guide (online supplemental appendix 1) was developed based on a literature review on the topic of retirement. After three test interviews, a few questions were modified, notably concerning the optimal timing for announcing retirement. The semistructured interviews allowed the interviewees to freely, confidentially and respectfully express their feelings, experience and emotions. Open-ended follow-up questions were used to obtain detailed descriptions. Probing questions, such as ‘Please tell me more about this’, were used to deepen the discussion. Interviews were conducted by FP (a male doctoral student, for whom it was his first experience in qualitative research) in the physician’s office. The research team had a previous experience in qualitative research. With the participants’ consent, all interviews were audiorecorded. No interviews were repeated. All interviews were transcribed manually. Transcripts were not sent to the participants for comment or correction.
Data analysis
The interviews were analysed using IPA. This inductive research method was chosen to better understand the social experience of patients regarding their GP’s retirement.15 The analysis included the repeated reading of the transcripts to understand the meanings conveyed, the identification of significant sentences and their reformulation in general terms. Microsoft Word© was used for categorisation into topics and subtopics. The data analysis was carried out by FP, who conducted the interviews and was best placed to understand them. The interviews were triangulated by two physicians trained in the IPA. The SRQR guideline was used in this study.16 Data analysis was based on theories such as Kübner-Ross’s grieving process and John Bowlby’s attachment theory.
Patient and public involvement
None.
Results
Eighteen semistructured interviews were conducted between January and April 2014. Only a few patients refused to participate but we did not ask them why. Sociodemographic data (gender, age, follow-up duration, frequency of visits and reason for consultation) were collected and are summarised in table 1. The mean duration of the interviews was 20 min.
Sociodemographic characteristics of the patients interviewed
The analysis of the interviews revealed three main themes, presented chronologically. First, a description of the GP–patient relationship, second the impact of the GP’s retirement on this relationship and third a projection into the future.
Patient–GP relationship
A trusted, unique and available declared doctor
This trust-based relationship was described by many patients. This trust allows patients to experience some freedom, to express their views, to confide, without being judged.
We know him well, we are free with him […] I felt free with him. (E7, F, patient followed for 30 years)
and with him, I would dare (E10, M, patient followed for 18 years)
Patients generally have no doubts about their GP and their skills and know that they can call them when needed, at any time.
He always knew how to answer our questions in a timely manner … (E16, F, patient followed for 27 years)
I listen and I really do it with my eyes closed, while with another physician, I think I would think twice before doing it (E16, F, patient followed for 27 years)
Patients choose their GP based on qualities or skills they value. Thus, the chosen GP is unique to his patients, this choice shows some loyalty to their GP.
There is nothing more important than a GP. […] He is the only person who can understand us. Nobody else than our declared doctor […] Throughout our life, there may be one or two GPs who impress us. (E3, F, patient followed for 24 years)
The GP often interacts with the whole family sphere, he knows the family members, their experiences, their medical and personal history. The GP’s retirement inevitably affects the whole family circle.
Dr. A knows my parents very well […] he also follows my daughter […] and my husband, thus we are all followed by Dr. A. He knows my daughter, so he looks after different generations. […] Between my parents and now the twins, who have grown up and each have their own child who is also followed by him. And he knows us perfectly. (E4, F, patient followed for 36 years)
It’s like losing a family member. (E17, F, patient followed for 35 years)
Gratitude
Patients are often very grateful to their GP. They know their dedication, their listening skills and are sensitive to their commitment. They thus have a real admiration and a deep respect for their GP.
He was so amazing. (E3, F, patient followed for 24 years)
I am really grateful to him, I admire him. We have lost someone of value […] I take my hat off to him. (E16, F, patient followed for 27 years)
A relationship strengthened over time
GPs are often considered the only person capable of building such a strong relationship with their patients. This link between the patients and their GP is built up slowly over time, and strengthens over the course of the relationship. When their GP retires, patients lose not only a physician, but also a friend, a confidant who knows their private lives and their experiences.
There is an emotional link […] that goes beyond the patient-GP relationship […] like a very strong link […] we get along well, I appreciate him … (E1, F, patient followed for more than 10 years)
I am attached to him. When I say I am attached to him, it is because I trust him […] This will change after 25 years of trust. (E3, F, patient followed for 24 years)
When you have been followed by someone for years […] a trust is established […], a relationship is built up between a physician and the patient which strengthens over the years and it is very difficult to break it. (E15, F, patient followed for 7 years)
GPs know their patients, their experiences, their history, their personal lives and their private lives. They therefore have a global vision of their patients and can provide them with customised care.
When someone has been following you for years, […] he considers the problem as a whole. (E11, F, patient followed for 17 years)
Retirement: a breakdown in the GP–patient relationship
Announcing retirement
Announcing their retirement deeply affects patients, and most of them remember this moment in detail. Thus, the way in which it is presented will have an impact on patients’ feelings. Patients want to be informed face-to-face by their GP during a consultation. Impersonal methods such as a poster in the practice are unpopular because they are seen as sudden.
I prefer to learn it this way, rather than through a letter or just stupidly receiving a simple phone call from the secretary saying ‘Listen, no, Dr. A will no longer be able to see you because he is leaving’. (E10, M, patient followed for 18 years)
It is better to receive information directly from the person concerned rather than through rumours. (E18, M, patient followed for 3 years)
The medical record is a symbol of this link between them and their GP. For some patients, getting their medical record back means the end of the relationship.
When he gave me back my record, I said to myself, that’s it, it’s over, he is giving me back my record […] I realized that it was really over […]. (E13, F, patient followed for 13 years)
For most patients, the announcement of their GP’s retirement is a real breakdown, the symbol of an end, of a chapter of their lives being turned. It is also a sudden event, often unexpected for patients. The links that have sometimes been built up over several decades, the complicity that has developed over the course of the relationship, the loyalty and trust that patients have placed in their GP make this breakdown more complex.
It’s a whole part of our life that will collapse. (E11, F, patient followed for 17 years)
We both had to break up. (E13, F, patient followed for 13 years)
GP’s retirement: from a peaceful experience to grief
The announcement of the retirement was experienced very differently depending on the patient, and on their personal experiences, situation, personality and, above all, the strength of the relationship between them and their GP. There was no standard profile, and each patient had different characteristics.
Some patients could not have imagined that their GP would be retiring. They could not anticipate such an event and remained speechless when they were informed of the news. Sometimes, patients felt abandoned and sad.
It came to me as a painful shock. I had never thought that … I always thought that I would die before […]. It never crossed my mind. […] I was not expecting that at all! Absolutely not! Actually, I'm stunned […], because I had never thought about it. (E5, F, patient followed for 26 years)
I yelled at the GP and said ’Oh no, you are not going to leave us, with all the diseases I have, you are not going to leave me without any medical supervision’ […]. (E3, F, patient followed for 24 years)
You are going to make me cry. (E17, F, patient followed for 35 years)
The patients most affected by their GP’s retirement shared several characteristics: a long medical history, chronic diseases, advanced age and a long-standing care relationship. Therefore, most of these patients had to consult their GP regularly or developed a strong relationship with their GP during their long follow-up. After several interviews, the following findings emerged: GPs know their patients, their experiences, their history, their personal lives, their intimate lives and therefore have a global vision of the person. From the patient’s perspective, this would allow better management and consistency of care. This would allow GPs to better meet the individual needs of each patient, faster and more effectively than any other physician. Conversely, younger patients with no chronic diseases consulted very occasionally, were less affected by their GP’s retirement because they had not been followed for long. Thus, some patients expressed doubts about the future, worried about losing their landmarks, finding a new GP and building a new relationship.
He knows when there is a real problem or when there is nothing serious […]. He knows the difference. Because we have known each other for a long time. (E4, F, patient followed for 36 years)
When someone has been following you for years[…] He knows all the diseases […] he sees the problem as a whole. (E11, F, patient followed for 17 years)
The very first question I had was: ‘Oh my god, what am I going to do, given my health problems. Who am I going to talk to? […] Who am I going to trust?’. (E3, F, patient followed for 24 years)
But who will follow us? How will he get to know us? Will he be as good? […] Things will change, especially in terms of trust. (E4, F, patient followed for 36 years)
This includes all the complicity, it’s like when you leave your husband after 20 years, you don't want to relearn the family, to get to know each other again, well, all these changes are quite complicated (E4, F, patient followed for 36 years). And if you have to go to other nearby towns to consult a doctor, well when you are my age, that is obviously a problem because I'm really alone and I do not drive anymore, so all that causes problems [ …] the older you get, the harder it is. You feel less safe. (E8, F, patient followed for 37 years)
Some patients were not worried about their GP’s retirement. On the contrary, they seemed happy for their GP and grateful for the work done.
It’s normal that they stop working; everyone has the right to retire. […] They should have a party for their retirement! (E4, F, patient followed for 36 years)
Projecting into the future: reconstruction
Perceived need for coordinating care
Patients understand that their GP has to retire but do not accept the closure of the practice and the absence of a replacement or successor. Indeed, at the time of the study, the GPs had not found a successor. This is perceived as an end, and leads to a break in continuity, often experienced with concern and misunderstanding. Patients would have preferred the appointment of a successor, combined with a transition period, or even alternated work between the GP and his successor.
He should hand over the reins […] work in pairs. (E11, F, patient followed for 17 years)
It is a pity that he has no successor. (E12, M, patient followed for 41 years)
Patients cited many obstacles to find a new GP, including institutional difficulties due to the medical desertification. Some patients mentioned this lack of replacement, which sometimes seemed to shock them more than their GP’s retirement.
But he needs to find someone […] there are fewer physicians in France. (E3, F, patient followed for 24 years)
Some patients blamed a dysfunctional healthcare system that is indifferent to their suffering.
Medicine is not doing well […] the way the public authorities take medicine into account […] the measures that are taken, cost-cutting measures […] this might be detrimental to people’s health […] (E10, M, patient followed for 18 years)
Patients’ concerns about changing their physician
For most patients, changing their GP generates fears and apprehensions: the fear of not being listened to as carefully, the fear of a less effective follow-up and a lack of knowledge of the individual (history, personal background…), seen as a loss of opportunities for the patient.
If you’re facing someone who does not know you, his vision will be a little more restricted […] the risk that he will be less effective at first, when the physician does not know you […] the whole psychological aspect that you cannot know […] when you don’t know the history of the patient. (E11, F, patient followed for 17 years)
This rupture implies a need for change: the need to build a new bond of trust, to adapt to a new caregiver. For most patients, there is no benefit to this change, it is just a chapter being turned, with no idea of what their future will look like.
We need to get to know the physicians and the physicians need to get to know their patients. (E3, F, patient followed for 24 years)
I will have to re-build a bond of trust […] I will have […] to get used to this new way of seeing things […] to go back to a mechanism, or a way of functioning again, to trust. (E10, M, patient followed for 18 years)
When you have an declared doctor, you are used to him, you know where he is, who he is, how he is. (E14, M, patient followed for 31 years)
Once you get used to a physician and have built a relationship with him […] it’s hard to change (E15, F, patient followed for 7 years)
A few patients sometimes considered visiting an emergency department because they were worried about not finding a GP once their physician will be retired.
Will I have to go to the hospital? This is ridiculous […], I might have to go to the emergency room […] I will have to find hospitals with emergency health and assistance services, perhaps for a simple bronchitis […] Will I really have to ask the emergency health and assistance services to take me to the hospital in the emergency room and will that really be my only option? (E5, F, patient followed for 26 years)
Beyond this concern, some patients saw the possibility of a new encounter.
It’s also good to have a new vision, a new approach. (E2, F, patient followed for 30 years)
It is not a relationship that is built up in one or two visits […] it is built up jointly between the GP and the patient and everything has to be rebuilt. That’s something we don’t want to happen. (E13, F, patient followed for 13 years)
Discussion
This study shows the strength of the link between the practitioners and their patients and supports the conclusions of several studies.8 9 17 This link, based on mutual trust, is built and strengthened over time. For some patients, the GP is a landmark in their lives since he interacts with the whole family sphere. The GP’s retirement corresponds to the breakdown of this link and of the loyalty established over the course of consultations. This breakdown was experienced very differently depending on the profile of the patients. Most patients, in particular those with the longest follow-up, go through an important acceptance process. Others experience this breakdown more calmly. In this study, the importance of a negative feeling of this separation between the GP and the patient could suggest a selection bias for certain participants or their statements compared with those who were more indifferent to this breakdown and would go unnoticed. This finding suggests that we should consider developing a more neutral interview guide to avoid any bias related to the interviewer.
Patients will have to find a new GP in the absence of a replacement or successor, in an institutional context that they consider unfavourable. They will have to make a choice based on personal criteria and to rebuild a relationship with their new GP. This retirement could be experienced more calmly by the patients if the announcement was made in advance by the physician. However, this would require a significant investment by the physician to inform each patient individually. In addition, the absence of a successor, aggravated in particular by the shortage of GPs, remains a challenge for the healthcare system, which needs to increase the number of physicians in training and then to facilitate the installation in the most disadvantaged areas in terms of access to care. This would make it easier for patients to find a GP and could reduce the apprehension of some patients. Indeed, in France, the declared doctor is the cornerstone of the healthcare system. Involved in both primary care and prevention, he is also the coordinator of patient care and a reference within the healthcare system.
Comparison with the existing literature
The link between the patients and their GP seems to be a relationship of trust or even of friendship according to the interviews we conducted. The importance of the relationship between the GPs and their patients is considered a key factor in primary healthcare.18 The importance of this relationship seems to strengthen over time. A study conducted in 2016 has investigated the GP–patient relationship in 297 patients.19 One of the key elements of the relationship and communication was the GP’s humility in this relationship, which improved their communication skills.
The breakdown in the GP–patient relationship due to the GP’s retirement is experienced as a loss by many patients. In our study, the patients were worried and thought they would have difficulty finding a new trusted GP. Similar results have been found in the study by Lam et al, which has shown that this transition period was experienced by patients as a vulnerability period.10
A literature review has systematically examined the GPs’ retirement planning. This study has found that knowing when their GPs planned to retire helped patients to make the transition and plans for the future.20
Strengths and limitations
Several studies have investigated the GPs’ perception of their retirement.4 Conversely, studies on patients’ feelings about their GP’s retirement are limited. In addition, this is a hot topic as the number of GPs retiring has increased in recent years without being replaced by younger physicians.21 22
The interview guide was developed based on a literature review on the topic of retirement with neutral expressions to avoid influencing respondents. Nevertheless, absence of negative responses regarding retirement deserves to be highlighted.
The average length of interviews appeared short. This could be explained by the beginner experience of the investigator but also by the conciseness of our interview guide. It only includes six categories, in online supplemental appendix.
The patients included were recruited from two GP’s practices, both located in Essonne, which could have led to a selection bias. If we had interviewed patients from other practices in other geographical areas, different results could have been obtained. Furthermore, conducting the interviews in the GPs’ practice could have influenced the patients’ responses. In addition, the fact that the interviewer was a man and presented himself as a future GP could also have influenced patients’ responses. Some participants refused to participate, and we did not ask them why, which could have led to a selection bias.
Conclusion
This study, which assessed patients’ feelings and expectations when their GP retires, allows GPs to consider the impact of their retirement on their patients. This study is relevant because, in France, the medical demography is particularly affected by a constant decrease in the number of active GPs. However, the patients’ comments confirm the importance of the role of the GP who is considered a landmark in their lives. It would have been interesting to reinterview the patients a few months after their GP’s retirement and to collect their feedback. This study confirms the importance of the link between the GPs and their patients and highlights the need to prepare patients for their GP’s retirement.
Data availability statement
No data are available. No additional data available.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants. The study was conducted in accordance with French regulations, which did not require the opinion of an ethics committee because it did not involve the human person as defined by law. In order to publish this article internationally, we obtained a favourable retrospective opinion from the CNGE (French National College of Teaching General Practitioners) Ethics Committee (IRB no. IRB00010804). As the interviews were anonymous, no written consent was obtained, but patients’ consent was obtained orally. A CNIL (National Commission for Information Technology and Liberties) declaration concerning data protection was mandatory and was made under registration number 2215462. Participants gave informed consent to participate in the study before taking part.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
YK and TD are joint first authors.
Contributors AK and JC were involved in the conception and design of this study. YK, TD, HF, KB, A-LC-C, SM, LP and FP were involved in data acquisition and analysis. All authors were involved in the conduct of the study. YK and TD reviewed this article. All authors approved the version to be published. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. JC is the guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.